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David Kieran, "Signature Wounds: The Untold Story of the Military's Mental Health Crisis" (NYU Press, 2019)
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Dr. David Kieran
Hello, everybody.
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Marshall Po
This is Marshall Po. I'm the founder and editor of the New Books Network. And if you're listening to this, you know that the NBN is the largest academic podcast network in the world. We reach a worldwide audience of 2 million people. You may have a podcast or you may be thinking about starting a podcast. As you probably know, there are challenges basically of two kinds. One is technical. There are things you have to know in order to get your podcast produced and distributed. And the second is, and this is the biggest problem, you need to get an audience. Building an audience in podcasting is the hardest thing to do today. With this in mind, we at the NBM have started a service called NBN Productions. What we do is help you create a podcast, produce your podcast, distribute your podcast, and we host your podcast. Most importantly, what we do is we distribute your podcast to the NBN audience. We've done this many times with many academic podcasts and we would like to help you. If you would be interested in talking to us about how we can help you with your podcast, please contact us. Just go to the front page of the New Books Network and you will see a link to NBN Productions. Click that, fill out the form and we can talk. Welcome to the New Books Network.
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Shu
Hello everyone. Welcome back to New Books Network. This is your host, SH1. Today I feel very happy to invite Dr. David Kieran to join us to introduce his new wish book Signature Ones.
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Dr. David Kieran
Oh, hi Shu, and thanks for having me on the podcast. My name is Dave Kieran and I am a historian of Warren Society and American culture. I currently hold the Colonel Richard R. Halleck Distinguished University Chair in Military History at Columbus State University in Columbus, Georgia. And I earned my PhD in American Studies at the George Washington University in Washington, D.C. and I was trained as a cultural historian who works on matters of military history, war and society, the relationship between the military and American culture, and Signature Wounds was the second book, the full length book that I wrote.
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Shu
Thanks so much for your answer. I'm wondering why you and how you take interest in. I think it's a very compromising field, the history of military mental health.
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Dr. David Kieran
Yeah, that's a great question. I didn't set out to write. The book I eventually wrote, I think is an important part of the story. I, as I said a minute ago, was trained in the American Studies department at George Washington University and I was really trained as a cultural historian. I still think of myself as a cultural historian. And I wrote my first book about the legacy of the Vietnam War and the way that Americans used the process of remembering Vietnam to talk about other events, to talk about World War II, and to talk about the wars in Iraq and Afghanistan and all sorts of events that got filtered through this national trauma that was Vietnam. And one of the things that I realized in writing the last chapter about of that book, which is about the wars in Iraq and Afghanistan, and you probably remember that everybody was comparing Iraq and Afghanistan to Vietnam. This is another Vietnam. This is not another Vietnam. It's going to turn into another Vietnam. And I ended up reading a lot of memoirs that had been written by Iraq veterans. And a lot of them were saying, well, we're not like Vietnam veterans. Vietnam veterans, they have ptsd. And I don't have ptsd. I'm fine. And at the same time, I was reading a lot of newspaper coverage about real concerns about veteran mental health, about traumatic brain injury, about post traumatic stress, about veteran suicide. And I thought, well, these two things don't really line up right. Why are veterans, the memoirs that I'm reading, so invested in saying that they are not having the psychological challenges that we, popular culture, associates with Vietnam veterans and. And wrongly so in many ways. But we're, as a culture, also quite aware of the psychological challenges that come from these deployments to Iraq and Afghanistan. So I initially set out to write a book that was going to be a cultural history of how mental health issues are being discussed in American culture, in popular culture, in media, in memoir, in fiction and film. But then I realized that if I were going to write that book, I should probably understand what the military was actually doing to treat these issues. And I address these issues. And once I started to ask those questions and peel that onion, so to speak, I realized that there was really a much more complicated story of what the army was doing to try to understand, diagnose, and treat mental health issues in the midst of two wars happening simultaneously then I thought was being captured in what I was reading in the popular press, in. In newspapers and magazines. And so I ended up deciding to write a book about how does a big organization like the United States army confront the massive challenge of mental health for the people who serve at this incredibly complex time of fighting two wars at the same time. So it became a much more institutional history of the army grappling with this big problem. And I ended up going down that path and not writing the book I'd intended to write, but writing a book that I found really rewarding once I got into telling the story.
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Shu
Thanks so much for your answer to my question. So now let's turn to your book. So for the first chapter of book, my question is that I'm wondering about the military mental health research before the September 11 attack on a behavioral health doctrine that the army would carry into Iraq and Afghanistan were first developed there.
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Dr. David Kieran
Yeah. So the first question I wanted to know is, what did. What did they bring with them when they went into the wars of the 21st century into Iraq and Afghanistan? I assumed they weren't starting from scratch and that they. They had some lessons that they were taking or some doctrine that they were taking with them. And so the first thing I wanted to understand is if you were an army medical provider in 2001 or 2003, what was it that you knew and what. How are you going to treat people? So what I learned was, is that the army had actually been studying this issue for a couple of decades. In fact, they'd been studying mental health back to the First World War at least. But really, in the 1980s, what the army had assumed would happen, the war they were planning for, was to fight the Soviet Union on the plains of Europe. And they imagined that that war would be very violent and very kinetic, but that it would be brief, that it would only last a couple of days. And so what they were really planning for was what they called battle fatigue or combat fatigue, where a soldier would have an intense, acute reaction to the violence of war, and that they could treat that person with rest, with a change of clothes, with a hot shower. They would normalize that this was a normal reaction to an abnormal situation, and that that generally, over the years, has proven effective right there. The Army's very good at treating acute combat stress. And one of the things they were not doing at the same time was they weren't investing a lot of research into PTSD into post traumatic stress or post traumatic stress disorder, because the prevailing view inside the army was that that was really something that the VA did, that that was an issue for veterans, not for active duty soldiers. And so that wasn't where they were putting their resources. But at the same time, the army was really invested in understanding what caused stress among deployed soldiers. And so Beginning in the 90s, an army researcher named Dave Marlow created these behavioral health assessment teams that would go off into places where soldiers were deployed, whether they were doing peacekeeping missions on the Sinai Peninsula or in the 1990s, when troops are deployed on peacekeeping missions to the Balkans. And they would go into these environments and survey soldiers and say, what is causing you stress? Is it distance from your family? Is it that you're in living in austere conditions, Is it that you are worried about some issue at home that you can't address because you're deployed? Are you worried about your safety? And they really developed this robust capacity to do research on the ground and understand how soldiers were experiencing deployments. And so those were the things that they brought with them into the wars when the wars began, which was, first, a really robust ability to create to treat acute combat stress. Second, a really robust ability to do research in real time on deployed soldiers to understand what their stresses were. And then they get to the wars of the 21st century, and they realize that these are going to be quite different wars. They're going to be longer. They're going to be wars that require multiple deployments. They're going to be wars that introduce new kinds of weapons like improvised explosive devices. And so they have to take what they know and what they've learned how to do over the course of the preceding couple decades and begin to adapt it to meet the challenges of the 21st century.
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Shu
Thanks so much for your answer. So now let's enter the second question. I'm wondering about how army researcher, drone researcher capacity developed during a peacemaking deployment in the 1990s to organize and deploy mental health adversary chain, so called mhats, to Iraq.
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Dr. David Kieran
Yeah. Yeah. So like I said, in the 1990s, a group of researchers at the Walter Reed Army Institute of Research, which goes by the acronym rare, led by Dave Marlowe, went out into the field and began to do surveys of how soldiers were experiencing their deployments. And these were actually related to surveys that were going on in corporate America at the time, where corporate corporations were just interested in employee satisfaction and employee stress. And. And the army picked that up and adapted it so that they could understand what is it that is causing our soldiers stress when we send them to the Balkans in the 1990s, to Somalia, to places like that. And so when the war in Iraq begins quite early, I want to say in the summer of 2003, the army says, well, we want to go over and understand what's causing soldiers stress in the combat environment, because there had been a little cluster of suicides by deployed soldiers. And the army was very quick to say, well, we need to figure out what's happening so we can address that challenge. So they sent a team led by an army officer named Carl Castro, who is a research psychologist, over, and they already had the methodology created to do that kind of research from what they'd done in the 90s with the deployments to the Balkans. So they could just adapt that and develop surveys and do focus groups and figure out how many soldiers in Iraq were feeling stressed or feeling anxious or were displaying symptoms of post traumatic stress or whatever it might be. And those what were called mental health assessment teams or mental health advisory teams became frequent missions to Iraq from by the officers assigned to rare, the Walter Reed Army Institute of Research. And that became some of the data that really drove the research that was being done as the army got a clearer picture of what were the items, the factors that were causing stress for soldiers? How many soldiers were experiencing symptoms of post traumatic stress or anxiety or depression? What was the relationship between a soldier's mental health and the number of deployments they'd been on or how long they've been deployed? Over the course of the five or six years after the Iraq war begins, there are a number of these mhat teams that go into Iraq and do the research and then come back and brief it to senior medical leaders, senior senior combat arms officers, the army senior leadership. And it becomes the mechanism through which the army develops the efforts to treat, diagnose, treat mental health issues for soldiers.
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Shu
So much for your answer. For the third question, I'm wondering about the intersection of debates over mental health and the growing anti war sentiments.
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Dr. David Kieran
Yeah, so. So one of the things I was really interested in in the book, and as I said a minute ago, I was trained as a cultural historian. So I'm really interested in how the military functions within the society that it serves and how Americans outside the military think about what's going on inside the military. And the Iraq war, of course, was incredibly controversial. There were, there were many Americans who either were suspect of the rationale for going into war from the beginning or became increasingly opposed to the war as the war went on. And it was more violent and lasted longer than many Americans had hoped or expected. And mental health became a really poignant means for people to express their opposition to the war. And the reason for that was because a frequent criticism of people who opposed the war was that any opposition of the war was harming the morale of the troops, that you weren't supporting those who were serving in the war. If you were speaking against the war and talking about mental health created an opportunity for people opposed to the war to say, look at the suffering and harm that is being delivered on these soldiers who have volunteered to go and serve their country in a misbegotten war. And so people could argue that they were in fact supporting the troops even as they opposed the war by Mobilizing mental health. And so mental health issues like post traumatic stress or veteran suicide or traumatic brain injury offered people in the anti war movement or people who were legislators who were opposed to the war, an argument that they could make that in some ways insulated them from criticisms that they were anti soldier or anti military because they could make arguments that as Barbara boxer did in 2006, if you love the troops and support the troops, you don't send them back to Iraq with a rifle and a bottle of antidepressants. I think I'm paraphrasing the quote, but she said something along those lines. And so arguments like that became a really potent way for people who are opposed to the war to make anti war arguments while still presenting themselves as pro soldier, pro veteran, pro military family.
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Shu
So thanks so much for. For next question. I'm wondering about how army work to understand why soldiers were recurrent. Why don't want to seek care to reduce stigma that surrounded doing so and to make care more available.
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Dr. David Kieran
One of the biggest issues that the army faced was the stigma that surrounded mental health issues. Military life, and particularly combat arms units are places where there's a real privilege placed on being tough and on being strong and on being self sufficient. And this is of course connected to discourses of masculinity. And so it was really hard for the army to convince soldiers that if that they might experience a mental health issue, they might there, there might be some psychological consequences to war that they needed to work through and to get them to come in for treatment. As George Casey, the chief former chief of staff of the army, said to me, it's hard enough to get these guys to come in when they have a broken bone. For them to come in with something for something they can't see is even more difficult. And especially that's true in a culture that privileges psychological toughness and physical toughness. And so the army worked really hard to normalize the idea first that being sent into a combat environment is abnormal, that human beings are not designed, they're not built to withstand seeing the kind of violence that happens in war as a matter of course. And so to come back from war and have to process that, and maybe that means you had some nightmares or you had some anxiety, or when you drive down the road, you get anxious when you're in heavy traffic because that's when an ambush might happen or an IED might go up. That is a normal reaction to the abnormal circumstances that you experienced in war. And so the army worked to develop a number of Structures to help soldiers first understand that and then seek treatment. The first was something that was called the battlemind program. The psychologist I just mentioned named Carl Castro and another woman named Amy Adler developed it, which was a set of principles that said the things that you learn how to do that help you actually survive and do well in a combat environment, like getting angry quickly or closing off your emotions or carrying a weapon everywhere are things that are really good when you're downrange in Iraq. And in fact, they might be the things that help you succeed and might be the things that keep you alive. But when you come back and you're with your family, getting angry really quickly or not being able to talk about how you're feeling and what your emotions are, or carrying a weapon everywhere might not be particularly good adaptations to a civilian environment. And so as much as it took you time to develop those skills when you were in Iraq and those, those capacities when you were in Iraq, you need to now work on returning to the baseline that you had when you, when you return, when you can't, when you, now that you've returned from that deployment. And that was a really powerful motivator for soldiers because it said, okay, these are, I'm not. I don't have a significant mental health problem. I am dealing with a normal reaction to an abnormal circumstance. Most people go through that process of readjustment and, and they return to their baseline mental health and they're fine. And then the army said, worked on a program, on a number of programs to make it easier for soldiers to come in and get care. One of the most important was an effort to get soldier get mental health care built into primary care so that a soldier who came in for their annual physical or a soldier who came in because they were having some kind of physical symptoms would also be asked about their mental health. And that way, as the army psychiatrist, Chuck Engel, who developed this told me, said, you have to already acknowledge and admit to yourself you have a mental health challenge if you're going to go see a psychologist or a psychiatrist. But a lot of times people will show up at their mental, at their primary care physician because they have some concern that they want to alleviate it. They can't sleep, they have a chronic stomach ache, they have really bad headaches, they have tightness in their chest because they're anxious. A lot of times these are they the physical symptoms or problems that a person might address by going to their primary care physician. And so Chuck's big idea was, how can we build mental health assessment and treatment into primary care, because that's where the people show up. And this idea that we could build a model that, again, helped normalize it, but made created more access for. For care. And the last thing the army did that I think is critical to breaking down the stigma is they began moving mental health providers out of medical units and out of medical facilities and embedding them into the units where soldiers served every day. Because what was happening is that if you needed a mental health appointment, you would have to make an appointment at the hospital, you'd have to miss work, you'd have to go over to the other side of the post you're stationed on and see that provider. And you'd have to explain to your boss what you were doing. And your boss might be skeptical of it. You know, the officer you report to. And what the army found is if we stationed a. Assigned a captain who's an army psychologist or psychiatrist to that unit and embedded it in them in there so that they were in that unit every day, they were out in the field training with those soldiers, that more people were willing to talk to that person, even informally, about what they were experiencing. And so this idea of therapy by walking around, or what somebody, I think, referred to as door jam therapy, where you just. You walk by and you lean on somebody's door frame for a while and talk to them in their office. And what that did is it normalized the idea that mental health care was available, that it worked. And as the officer who developed that, his name is Chris Ivany, said to me, it might be a situation where the battalion commander still is skeptical of mental health on the whole, mental health treatment on the whole. But he likes Dr. Jones, who sees all of his soldiers, so he's more open to it. And so the army understood that soldiers had a really hard time because of the culture they came from acknowledging that they had a mental health issue or needed mental health care, but by creating more opportunities for them to see it as a pretty typical reaction to being in war and more opportunities to get care in the places that they went all the time. The army did a good job breaking down the barriers to. To getting more people into the care they needed.
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Shu
Okay, thank you so much for your answer. So, for the following question, I'm wondering about how the army's efforts fell short of ensuring better mental health care for all families.
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Dr. David Kieran
So this is the first war that the army has fought where the soldiers have been all volunteers and where many of the soldiers have families. So beginning in the 1980s, the army realized that if we're going to sustain the all volunteer force, and especially sustain it during wartime, we have to take care of families. And certainly that accelerated in the aftermath of the beginnings of the Iraq and Afghanistan wars because for the first time the army was faced with the reality that the majority of the people they were sending overseas to, to fight had a spouse and usually children that were left back at home. And that's a very anxious time for a family. Right. They're worried about the well being of the person who's deployed, obviously, and whether they're going to be safe. They're worried about whether they're going to get a knock on the door or a phone call telling them that their family member has been injured. They're worried that, as one person said to me, I remember driving home every day and coming around the bend where my house was and hoping there wasn't a government sedan with a couple of officers and a chaplain waiting to tell me my husband had been killed. And for children, it's very anxiety provoking, right? Their dad's not there or their mom's not there. They're trying to go to school to have a normal childhood. But they are instead faced with this idea that, you know, my parent is far away. I don't know what's happening to them. I can't see them. I'm seeing terrible things on the news. And so the army worked really hard to figure out how to address this. But the biggest challenge that they had was two. One is that they didn't have enough providers at all even to meet the needs of the uniformed people. And then to add to that, the challenge of ensuring that spouses, children got the care they need. There was a real shortage of providers. The second is it's really hard to get the family members to go and seek care just as it is the soldiers. But the army has the virtue. I suppose I'm going to use the word virtue. They can order a soldier to sit through a briefing. They can order a soldier to go have a psychological evaluation or to go see a physician. But the spouses and children are not in the Army. They can't be. They don't. There's no mechanism to kind of force the care, right? And so the army did care about this issue. And I think this is something that I really emphasized in the book, especially when George Casey became Chief of Staff, because George Casey is from a Gold Star family. I'm sorry, his father was the highest ranking officer killed in the Vietnam War. And so he said, I understood what families went through when they lost a loved one, when a loved one's deployed. And he was very compassionate and very concerned about addressing these issues and did put a lot of resources behind it into augmenting what were called family readiness groups, which were groups run by army spouses to support one another while the units were deployed, to create more child care centers, more facilities on posts where spouses could get out of the house and go exercise or meet with other people in the community to make sure that, that army schools were concerned about these issues. But the reality was that the pace of the wars and the deployment needs that the army faced and the lack of resources could just never keep up with the strain that army families were feeling over the course. Yeah, yeah.
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Shu
Thanks so much once again. So for next question, I'm wondering about accelerated efforts understanding traumatic brain immunary injury.
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Dr. David Kieran
I mean, so traumatic brain injury was a term that became quite popular and frequently used in the 21st century. Of course, traumatic brain injuries happen in war all the time. Right. You could think back to what was called shell shock and the, and certainly soldiers had had head injuries with some frequency during war, right, because they are involved in a violent and dangerous business and they hit their heads or they have an impact wound from a shell or a, a bullet. And so traumatic brain injury is a term that comes into popularity, but it really refers to either a physical impact to the head or some kind of penetrating head injury. But what became the major issue in the wars in Iraq and Afghanistan was the question of how traumatic brain injury, the incidence of traumatic brain injury increased because of the advent of the improvised explosive device as the signature weapon of the wars, that many soldiers, if they were injured, were being injured because their Humvee or their truck hit an ied. And the question that what happened is soldiers began to complain of symptoms like chronic headaches, sleeplessness, anxiety after that had happened. And the debate became, well, is it possible that the concussive blast wave of an explosion can damage the brain? And all of the research that had been done up until the early years of the 21st century had said, well, concussive blast waves damage gas filled organs. They damage the lungs, the intestines, the bladder, the brain. That's not a gas filled organ. So unless there's actually an impact that causes the brain to hit the skull as happens in a physical injury, like think of a person head hitting the dashboard of a car in a car accident, there's probably not going to be a traumatic brain injury. And yet there were all these soldiers who seemed to have Symptoms. And So in the 21st century, the army devoted a lot of effort to researching the dynamics of blast and whether a blast could in fact, cause a traumatic brain injury. And what they. The hypothesis they took was, okay, a blast wave is a physical force, and so is a person's fist or a soccer ball or anything else. So if it's possible that a fist or a soccer ball can injure the brain, maybe the physical force of the blast wave could. And over the course of several years, army neurologists did research that first with some swine studies using pigs, and then they did a study with people who, Marines who were being trained to be breachers, which are people who use explosives to blow open doors on buildings. And they were able to do research that said blast waves do in fact, have a sufficient concussive power to damage the brain and cause cellular damage within the brain. So that's an important scientific advance to understand that. But it opened up all sorts of questions within the research community and in the deployment community, because once you know that, but then the question becomes, okay, well, how do I. How close does a soldier have to be to the blast in order to have. Be susceptible to a brain injury? Well, that depends on a number of factors. How big was the blast? How big was the bomb that went off? Were they wearing their helmet or were they not wearing their helmet? Were they in a closed environment or an open field? And so coming up with guidelines for how to assess and treat people based on their proximity to a blast was an imprecise science. And they had to sort of think about, okay, what is the best guidelines we can come up with based on the science that we have some certainty in and what we're seeing in terms of what a soldier is experiencing in Iraq and Afghanistan? And the other issue that was complicated, another issue that was complicated is what's the relationship between post traumatic stress and traumatic brain injury? Because a lot of cases where a person in the civilian world might get a traumatic brain injury, think of a football player getting a concussion. That's not a otherwise particularly dangerous or psychologically stressful environment. And in fact, it's a place where you're going to be surrounded by people who care about you and want you to do well, whether that's your teammates, your coaches, the trainer, the ob, the people in the stands. But the combat environment is different. In that environment, if you have a concussion or a blast wave and maybe you're unconscious for a few minutes and you wake up, you might be in an environment where people are shooting at you, where some of your friends have been injured or killed, where your vehicle is on fire. And the question became that an incident that created a traumatic brain injury might also create psychological trauma. And so how do you separate out the two? Understand if a person has one or the other or neither or both, and how do you treat them? Because you have to treat. You can't treat one and ignore the other. And you can't misdiagnose. You don't want to misdiagnose. And so it became a very complicated medical challenge for army researchers first to understand and then to get down to the level of the enlisted medic, who's going to be the person on the ground treating the person, or the doctor in theater, who's going to be the person treating them. And then the last question is, you know, what kind of concussion protocol do you have for a soldier who's had either a blast induced or impact induced traumatic brain injury in terms of how long do you need to rest them and how. When can they go back to doing their job? And this was a really complicated question because if you had a mission and you'd sent 10 guys out to do some kind of mission and there's an explosion and three of them have a traumatic brain injury, well, the next day you need to have another mission you need to do. So do you not do the mission because you don't have the full complement of 10 people, or do you send seven people out to do a job 10 people are supposed to do because that puts the other seven people at greater risk. And so managing the responsibility to care for soldiers and make sure they got the treatment they needed and to do what the medicine medical research said was best for them and also to meet the needs of an army at war became a really complicated question for army leaders and army medical leaders to, to resolve. And I think it's really important here to say that, you know, the army was trying to figure this out at the same time civilian medicine was right. This was in the era where increased attention was being paid to NFL players and concussion, where high school athletes were being asked to wear mouth guards and head protection in sports more than they had been in the past. And one of the researchers I talked to said there's. There's no such thing as military medicine. We don't have different medicine. What we have is the best civilian medicine, and we go to war with the best civilian medicine has to offer. So. So at the same time the army's trying to figure out concussion, they're looking at nascar, they're Looking at the NFL, they're looking at the American Academy of Sports Medicine and saying, what kind of guidance do you have for us about how to treat concussion? And so this is a civilian problem and a military problem, but certainly escalated in the time period that I write about for the military.
- [35:40]
Shu
Thank you so much for the answer. For the next question, I'm wondering about AMI's effort to address the rise of inactive duty civilians.
- [35:49]
Dr. David Kieran
Side. Yeah, that was actually the issue that got me interested in writing this book in the. In the first place, as I read an article in the New York Times that the army had determined that deployments to Iraq and levels of post traumatic stress disorder did not correlate at all to active duty suicide. And I thought that was a really interesting result. And it was, frankly one I was skeptical of initially. And so I started doing some research into it, and that really got me on the road to writing this book. So in 2007, for the first time, the suicide rate among active duty soldiers was higher than the civilian rate in the United States. And that was shocking and very unsettling inside the army because typically, soldiers are not a population that has a high suicide rate. And that's because soldiers are generally healthy, and they don't have many of the conditions that are. That are linked to high incidence of suicide would disqualify you from service in the military. So soldiers typically have a pretty low suicide rate. So when it began to tip up in this moment about the midpoint of the Iraq war, many people inside the army and outside the army also began to looked at it and said, okay, something's going on here. Clearly this is related to the war. How could it not be? And so the army stood up a suicide prevention task force and went and looked at every soldier who had died of suicide over the past year. I think this was 2008 or 2009. And. And they tried to see, okay, was it related to their. Did they have. How many deployments had they had to Iraq or Afghanistan, did they have post traumatic stress disorder? Had they had some major life incident? And the answers were really unsatisfying because there was no single issue they could point to. They couldn't say, oh, people who've been to Iraq three times or more have a higher suicide rate, or people who've been involved in heavy combat have a higher rate of suicide. There was just no correlation between any combat or deployment experience and any indication that the person would. Would die by suicide. What they did find is that usually something else had happened in that soldier's Life prior to the death. And often it was the end of a relationship, a breakup with a girlfriend or a divorce. It was a substance abuse issue. Maybe a soldier got a DUI or had been referred for substance abuse treatment. Maybe it was that they had gambling or credit card debt, but there was some, or it was something that was going to imperil their ability to stay in the army and continue to serve or maybe, or get promoted. And so they, they realized that soldiers who died by suicide had had some other adverse things happen in their lives. And the question then became, well, in the army, your life is under a lot more scrutiny and surveillance than it is for you or I, who are civilians, right? The army can tell you when to go to bed at night, when to get up in the morning, whether you can have a beer, which places in town you can go in to drink that beer. They can tell you what your height has to, your height, weight ratio has to be all sorts of things that the civilians don't deal with. So the question became, well, if, if we started to see if, if we could have looked back and say, oh, this soldier was starting to slip into patterns of behavior where they were doing things that were, were harmful, they had a substance abuse issue, they had been arrested for domestic violence, they had racked up tens of thousands of dollars in credit card debt. And why didn't somebody catch that? Why didn't we intervene earlier to make some, help this soldier, make some changes in their life and possibly save their life in the end? And the answer became, the answer they arrived at was that in the kinetic, high paced world of deployments that the Iraq and Afghanistan wars required, junior senior NCOs and junior officers had lost what they called the art of garrison leadership, which was leading an army in garrison on a post, not downrange and deployed. And that in the old days, you know, the 80s and the 90s, if you were coming up as an officer, it was expected that you would know what was going on in your soldier's life and that you would visit their homes and make sure that there was food in the refrigerator and the lights were on and the water was water that came out of the sink and that the house was relatively clean and, and that the children were being well treated and, and that was the responsibility of a soldier, of an officer to know their soldiers and know what was going on in their soldier's life and to, to know if, you know, Sergeant Kieran's wife is, has a, has a health issue or Sergeant Kieran is going through a divorce. Right now, or, hey, I've noticed that he seems to be showing up to work with a hangover three or four days a week. All those sorts of things that were the responsibility of an officer became. I won't say they became less important, but they, There was so much other stuff that was taking priority, which was, you know, getting ready to deploy, training up for a deployment, going to Iraq or Afghanistan, and surviving that deployment and then coming home. And, and so this, these issues that were really important in some ways took a back seat. And the army leaders said, if we're going to address the problem of suicide, what we need to do is make, is make it a leadership issue and get our leaders to back to this baseline of, of garrison leadership that we expected before the wars began so that they will recog recognize when a soldier is starting to struggle. And we can get them involved in counseling or get them to go see the chaplain or whatever, get them into substance abuse treatment, whatever they might need before they get to the point where they make a permanent decision to what are in most cases, temporary problems.
- [42:33]
Shu
Thanks so much for the answer. So for last question today, I'm wondering how the Department of Veteran affairs work to address the rising number of veterans taking their own lives.
- [42:45]
Dr. David Kieran
Yeah, this was, this was the, the other side. So I, I spent most of my time in the book writing about the army, but certainly veteran suicide was a major issue that Americans were deeply concerned about in the time of the wars in Iraq and Afghanistan. And there was a narrative that the VA was not doing enough to address veteran suicide. And what I found in the, doing the research for this book was that actually they had done an incredible amount to try to reach out to veterans and create the conditions that would get them into health care, make sure that they had access to counseling, make the VA more friendly to a new generation of veterans. Right. The va, in the minds of a lot of Iraq and Afghanistan veterans is where their dads or their grandparents went. Know their, their World War II era grandparents and their Vietnam era dads went for care and it wasn't for them. So the VA had to rebrand in a certain way and say, we understand you and we understand your experience and we want to and we're here for you. They also had worked really creatively, and I think, I think this is really important for people to know that the VA worked really creatively to do first surveillance on veterans and to, to really understand every month how many veterans were coming in for mental health care. What were they, what, what diagnoses did they have who was having suicidal ideations, who was. How many suicide attempts were there, how many suicide, how many people died by suicide. And they broke that down every month by every VA region in the country. So hundreds of VA hospitals reporting that data in and then crunching that data to really try to understand where can we make positive interventions. And the, the thing I think they did that was most important, okay, the research shows that the person who is having a suicidal ideations, there's a four or five minute window between when a person thinks about dying, taking their life and when they might make an attempt. And if you can intervene in that window and stop a person there, that is a critical, critical point where if you can stop a person from making an attempt to end their life, then you can intervene in, get them into the stream of care that they need. And so the army, sorry, the VA stood up the Veteran Suicide Hotline, which was incredibly impactful in terms of creating an opportunity for veterans to pick up the phone and call and get immediate care. They also put the Suicide Prevention hotline number on the caps of all the prescription bottles that the VA sent out so that a veteran, if they were going to take their medication on a daily basis, they saw that number. But in a more dire situation, a veteran who might be thinking of overdosing, they would see that number before they could even open the bottle. And that would just create another opportunity to get that veteran into care. They partnered with the National Shooting Sports association to in an effort to send as many gun locks as they could to veterans around the country so that veterans firearms would be secured, which is important not just for veterans, but for everybody who lives in the home where there are firearms, they should always be secured like that. But it was another barrier which is that if a veteran who was in crisis had to pause and take the gun lock off and reassemble the gun, maybe that would be enough time for them to make a different decision and say, and save their lives and then reach out for care. So the va, I think, was really invested in this issue. It was really creative and how it approached it. And it took the approach that the most important thing that they could do was to ensure that they were doing all they could to what, what they called limit access to lethal means. Make it so that veterans who were at risk of suicide didn't have access to medication where they could overdose, they had less access to firearms and things like that. And then creating the conditions where the VA positioned itself as an avenue for care for veterans.
- [47:18]
Shu
Thanks so much for your answer to all my question today. I really appreciate that. So at the end of our episode today, I want to directly talk to our audience, to our listeners. So thanks so much for listening to Dr. Kiran's discussion about his fantastic new book, Signature Ones. If you happen to take interest in in like the history of military, history of mental health, or both, I personally highly recommend you consider buy a copy of this book. Please take notes of this. Now is the time. Take notes of this book's title. Signature one so thanks so much for listening to our podcast today. Have a good day.
- [48:12]
Dr. David Kieran
Sam.